In California, as across the United States, the young uninsured are a key piece of the new Affordable Care Act (ACA) marketplace puzzle. Having a good-sized component of young people, with their generally more robust health and less frequent need for medical care and prescription drugs, in the newly created insurance pools would provide an important counterbalance to the incoming group of Americans who had previously been locked out of coverage because of preexisting health conditions.

In this data note, we take a closer look at a broadly defined ‘young invincible’ population using a recently released baseline survey of California’s uninsured population by the Kaiser Family Foundation (KFF). The representative, probability-based sample survey is the first of what is expected to be a series of four surveys that will track the views and experiences of the same group of people over the next two years.1 For the purposes of this analysis, we are defining the young uninsured as those Californians aged 19 to 34 that have not had insurance for at least two months and by their income and status as citizens or permanent residents should be eligible to participate in the ongoing insurance expansion under the 2010 health law. Overall, these young uninsured Californians make up nearly half (47 percent) of the state’s adult, eligible uninsured population.2

Who are California’s young uninsured?

The majority of the Golden State’s young uninsured are men – 59 percent are male, 41 percent are female – a distribution not significantly different than California’s eligible uninsured as a group, which tends to be disproportionately male due to Medi-Cal’s previous rules regarding eligibility. Roughly half are Latino, much like the state’s uninsured population as a whole. Compared to the state’s older uninsured population, the young uninsured are more likely to report being American born citizens: 78 percent say so, compared to about six in ten of those age 35 and over. Like the rest of the eligible uninsured, a large share live in very low-income households, with roughly half (48 percent) saying their household’s annual income is 138% or less of the Federal Poverty Level (FPL) Medi-Cal eligibility ceiling.3

Figure 1

19-34

35-49

50-64

Race/Ethnicity

White

29%

29%

42%

Black

7

6

7

Asian

13

5

5

Other

3

11

7

Hispanic

48

49

39

Were you born in the United States or in another country?

U.S.

78%

58%

62%

Another country

22

41

37

Eligibility Level

Medicaid target group (138% FPL or below)

48%

49%

42%

Exchanges subsidy target group (139% – 400% FPL)

41

37

43

More than 400% FPL

5

11

11

The 19 to 34 year olds are also different in predictable ways in terms of their stage of life: more than six in ten (63 percent) have yet to marry, compared to fewer than two in ten among older uninsured; roughly one in four (28 percent) have a dependent child at home, compared to more than half (55 percent) of those in the middle age group; and roughly one in eight (12 percent) are students.

Figure 2

19-34

35-49

50-64

Marital status

Married

21%

47%

45%

Living with partner

10

15

9

Previously married

6

20

29

Never married

63

17

18

Are you a parent of a child under age 19 living in your household?

Yes

28%

55%

18%

No

72

45

82

Employment status

Employed

64%

59%

49%

Unemployed, looking

17

22

22

Unemployed, not looking

3

4

7

Student

12

1

<1

Other

5

14

21

Education

Less than high school

13%

31%

27%

High school

34

26

21

Some college

37

30

38

College or more

15

13

14

Young, but not new to lack of coverage; Health insurance history differs from older groups

Though these Californians are relatively young, most of those aged 19 to 34 report that they have been uninsured for a significant length of time. Overall, six in ten among the young uninsured say they have been uninsured for at least two years. Four in ten have lost insurance within the past two years, compared to roughly three in ten among the older groups. As is true for the rest of the state’s uninsured, the main reason this group remains uninsured is cost-related: half (48 percent) say the main reason they don’t have health insurance is that it’s too expensive.

Figure 3

19-34

35-49

50-64

And how long have you been uninsured?

Less than two years (NET)

40%

27%

29%

2 months to less than a year

19

14

15

1 year to less than 2 years

21

13

14

Two years or more

60

72

71

This group does stand out as having a different past relationship with health insurance coverage compared to those 35 and older. While a majority of those aged 50 to 64, and nearly half of the middle-aged group, say that their previous source of health coverage was through an employer, only 22 percent of those under age 35 say the same. Newer to the workforce, their experience with employer-sponsored coverage is obviously more limited. Instead, one in four say that before they were uninsured they were on their parents’ health plan, and nearly as many (22 percent) say they were covered by Medi-Cal or another state’s Medicaid program (programs that have been required to cover low-income youth until they turn 19). Four in ten among this group have been on Medi-Cal at some point in the past. Note they are also the group least likely to have shopped for health insurance in the individual market: 20 percent have done so, roughly half as many as among older uninsured Californians. In this respect, the exchange experience will be even newer for this group than for other uninsured Californians.

Figure 4

19-34

35-49

50-64

Before you were uninsured, what was your main source of health insurance coverage?

Plan through your/your spouse’s employer

22%

47%

59%

Coverage under your parents’ plan

26

4

1

Medicaid/Medi-Cal

22

21

9

Never had insurance

23

21

17

Have you, yourself, ever received health insurance through Medi-Cal, or not?

Yes

40%

39%

27%

No

58

60

73

Have you ever tried to buy health insurance on your own, either for yourself or for your family, or not?

Yes

20%

37%

44%

No

80

63

56

The ‘benefits of youth’ are real, but limited: Half financially insecure and nearly as many say health needs not being met

This group of uninsured report experiencing at least two of the benefits of youth: They are less likely to report feeling financial stress than their older peers, and they are more likely to say they are in good health.

Across several fronts, the young uninsured report feeling less financial insecurity than those in the thick of child-rearing or in the pre-retirement years. Overall, half say they feel secure when it comes to their financial position, compared to roughly a third of those aged 35 and over. They report less worry about their income keeping up with rising prices and about having enough money for what must seem a far-distant retirement horizon.

Despite this comparatively optimistic picture, it’s important to keep in mind that this still leaves half among this group saying they do not feel financially secure at this point, an important consideration when it comes to evaluating any costs that might come with new insurance coverage.

Figure 5

19-34

35-49

50-64

All in all, how financially secure do you feel?

Secure

51%

38%

32%

Insecure

49

61

67

“Very worried” about not having enough money for retirement

51%

68%

68%

“Very worried” about income not keeping up with rising prices

50%

67%

68%

Those under age 35 are also more likely than older Californians without coverage to say they are in good health, with three in four saying so. They are also less likely to report having a disability, handicap or chronic disease. But while just over half in this group – 54 percent – say that their health needs are basically being adequately met at this point, the rest – 45 percent – say they are not getting the care they need.

Figure 6

19-34

35-49

50-64

In general, would you say your health is…

Excellent/very good/good

74%

63%

51%

Fair/poor

25

36

49

Does any disability, handicap, or chronic disease keep you from participating fully in work, school, housework, or other activities?

Yes

8%

15%

25%

No

91

85

75

Overall, how well would you say your health needs are being met today?

Very/somewhat well

54%

46%

48%

Not too/not at all well

45

54

51

California’s young uninsured report plenty of trouble getting and paying for the health care they need

Their overall good health, however, does not protect this group from incurring medical bills on occasion and then having trouble paying them.

Young people are just as likely as any other uninsured state resident to say they have had trouble paying medical bills over the past year. Overall, four in ten (39 percent) say so – and they report just as much worry about paying for health care going forward. Just over seven in ten of those aged 19 to 34 years say they are “very worried” about how they would pay for health care in the case of a serious accident or illness, putting their concern about a catastrophic medical event well within range of uninsured Californians of any age. They are somewhat less worried about not being able to cover the cost of routine health care services: 44 percent are very worried about this, compared to about 55 percent of older uninsured.

Figure 7

19-34

35-49

50-64

In the past 12 months, did you have any problems paying medical bills, or not?

Yes

39%

43%

42%

Used up all or most of your savings because of medical bills

18

18

24

Been contacted by a collection agency because of medical bills

20

20

18

Spent less on food because of medical bills

18

20

26

No

61

56

58

How worried are you about not being able to pay medical bills in the event of a serious illness or accident?

Very worried

73%

78%

77%

Somewhat worried

20

16

16

Not too worried

5

2

5

Not at all worried

2

4

3

How worried are you about not being able to pay medical bills for routine health care services?

Very worried

44%

56%

55%

Somewhat worried

32

25

26

Not too worried

19

14

13

Not at all worried

6

5

6

One way this generation deals with the problem of hard to pay medical bills is, like the rest of the uninsured population, by skipping health care, even when they feel they need it. Roughly six in ten (59 percent) in this population say that they’ve gone without needed health care since they’ve been uninsured because of the cost. This is somewhat lower than their older compatriots, but still a majority among a supposedly “invincible” population.

The large majority of young people – about eight in ten – say it is difficult for their family to afford health care, though they don’t express quite as much intensity on the issue as older uninsured Californians. For example, 42 percent of those aged 19 to 34 say their family finds it “very difficult” to afford health care, compared to 63 percent of those aged 50 to 64.

Figure 8

19-34

35-49

50-64

Percent who say they have done each of the following during the time that they’ve been uninsured because of the cost…

…gone without health care you thought you needed

59%

66%

72%

…put off or postponed preventive health services, such as a yearly check-up or routine test

65

68

75

…skipped dental care or checkups

68

72

75

In general, how easy or difficult is it for you and your family to afford health care?

Very easy

2%

4%

2%

Somewhat easy

16

8

4

Somewhat difficult

37

32

27

Very difficult

42

52

63

Majority of young uninsured say they feel the need for health coverage

Perhaps because of these worries and negative financial experiences involving medical bills, about three in four of California’s young uninsured say they feel the need to have health insurance. On the other hand, one in four say they feel healthy enough that they don’t really need coverage.

And the majority of young people – six in ten – say that health insurance is worth the cost.

Figure 9

19-34

35-49

50-64

Which of the following comes closer to your view?

Health insurance is something I need

74%

84%

85%

I’m healthy enough that I don’t really need health insurance

25

14

14

Would you say that health insurance IS or IS NOT worth the money it costs?

Health insurance is worth the money

61%

53%

53%

Health insurance is not worth the money

32

40

38

More positive views of the ACA, but low information

The uninsured 19 to 34 year olds look roughly the same as the rest of the state’s eligible uninsured population when it comes to general views of the health law: somewhat more positive toward the law than the American public nationwide,4 but even more likely to feel they don’t have enough information to understand how it will impact them personally. Overall, half of those under 35 have a favorable view of the ACA, 27 percent an unfavorable view and 21 percent don’t have any opinion. Though many have a sense of whether or not they like the law as a whole, at least at the end of the summer far fewer felt confident they understood how the law’s changes would affect their own lives. Overall, seven in ten (69 percent) said they don’t know what to expect in terms of personal impact. And as of the end of August, most had heard little or nothing about the Medi-Cal expansion (77 percent) or the creation of the Covered California insurance marketplace (88 percent), similar to their older peers.

Figure 10

19-34

35-49

50-64

As you may know, a health reform bill – sometimes called Obamacare – was signed into law in 2010. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it?

Favorable

51%

44%

49%

Unfavorable

27

30

35

Don’t know

21

26

17

Do you feel you have enough information about the health reform law to understand how it will impact you and your family, or not?

Yes

30%

26%

30%

No

69

73

69

Young people not immune to confusion regarding eligibility

Because of this limited exposure to recent information about the rollout of the insurance coverage expansions under the ACA, it is perhaps not surprising that as of late August, many young people in California were not aware of their potential eligibility for either subsidy assistance on the exchanges or inclusion in the expanded Medi-Cal program. Awareness of the availability of tax credit help when purchasing through Covered California was particularly limited at this early point. Overall, roughly seven in ten young people identified as in the appropriate income group either thought they would not be eligible for financial assistance (43 percent) or weren’t sure (26 percent).

Figure 11: AMONG THOSE IN EXCHANGE TARGET GROUP (>138% – 400% FPL)

19-34

35-49

50-64

As far as you know, will you personally be eligible to get financial assistance from the government to help pay for health insurance as a result of the health care law, or not?

Yes

32%

15%

28%

No

43

47

39

Don’t know

26

38

33

Uninsured Californians of all ages, including younger folks, were more likely to recognize their potential eligibility for the Medi-Cal program, a program they may be more familiar through previous exposure or family and friend networks. Still, roughly four in ten of the 19 to 34 year olds expected to be eligible for Medi-Cal were not aware of this eligibility as of August (25 percent in the target group thought they would not be eligible, and another 17 percent had no idea either way).

Figure 12: AMONG THOSE IN MEDI-CAL TARGET GROUP (≤138% FPL)

19-34

35-49

50-64

As far as you know, will you personally be eligible to get insurance through Medi-Cal as a result of the health care law, or not?

Yes

57%

54%

44%

No

25

26

28

Don’t know

17

20

29

What to expect in 2014

When told or reminded that “nearly all Americans [will be required] to have health insurance by 2014 or else pay a fine,” a clear majority of the youngest group of uninsured Californians – 58 percent – said they planned to get coverage next year. At least as of late summer, roughly a third thought they would remain uninsured.

Figure 13

19-34

35-49

50-64

As you may know, the health care law requires nearly all Americans to have health insurance by 2014 or else pay a fine. Do you think you will obtain health insurance in 2014, or do you think you will remain uninsured?

Will obtain health insurance in 2014

58%

48%

52%

Will remain uninsured

33

33

27

Depends on the cost

4

11

12

As is true in other age groups, a large majority of young people said that if they were told they were eligible for Medi-Cal, they would sign up.

Figure 14

19-34

35-49

50-64

If you were told you were eligible for Medi-Cal, would you want to enroll, or not?

Yes

82%

88%

84%

No

13

8

11

A note on process issues: Compared to older uninsured, the young are more involved in internet economy

Though there are many avenues for Californians to learn about the new insurance options, including in-person and phone opportunities, much of the shopping and learning is structured around the web. This is an advantage for younger state residents, as compared to the older uninsured population, the 19 to 34 year olds are more likely to have access to the internet overall, more likely to have internet access in their own home, and more likely to have at least occasionally bought things online. Still, it’s worth noting that just under half (44 percent) have rarely or never made an online purchase.

Figure 15

19-34

35-49

50-64

Percent who say they do NOT have internet access…

…at home

20%

31%

34%

…anywhere

5

18

24

How often do you use the Internet to buy a product online, such as books, music, toys or clothing, or not?

Very/somewhat often

28%

19%

14%

Just occasionally

27

20

20

Rarely/never

44

62

66

What Next

Most of California’s youngest uninsured residents report that they are healthy, but like the rest of the uninsured, most say they have skipped needed medical care because of cost during their period of uninsurance and they report a high degree of worry about what would happen if they were to become severely ill or be injured. Many have struggled to pay the health bills they have incurred. And perhaps because of all these reasons, most say that they feel the need for health insurance.

At the same time, in the months before open enrollment in California, this generation of the uninsured was just as likely as any other to feel they didn’t understand the health reform changes coming down the pike and to have heard little about the state marketplace or Medi-Cal expansions. And as a consequence, there likely remains a fair bit of eligibility confusion to sort out. Add to this the fact that half of this younger group feel financially insecure and only one in five have shopped for insurance before on their own, and it becomes clear that the open enrollment period will be a learning experience on all sides.

Over the next several months many of these young Californians will be learning more about the health coverage available to them via various ACA channels, and many will take steps to understand the costs and benefits such coverage will offer them. Beginning next spring, KFF will be back in the field revisiting these young people and asking them to reflect on their experiences – or lack of experience – with Medi-Cal and the exchanges.

Methodology

The survey of California’s uninsured population was designed and analyzed by public opinion researchers at the Kaiser Family Foundation. Fieldwork was conducted in English and Spanish via telephone by SSRS, an independent research company, from July 11 through August 29, 2013, among a representative sample of 2,001 adults ages 19 to 64 living in California, who reported having been without health insurance for at least two months at the time of the interview. Of the 2,001 respondents, 990 were interviewed via landline, and 1,011 via cell phone. The current data note is based on the 515 respondents that were between the ages of 19 and 34 at the time of the interview, and that qualified as being part of the ‘eligible uninsured’ (those who reported being U.S. citizens or permanent residents, and thus eligible for the health insurance expansion under the Affordable Care Act). The margin of sampling error including the design effect for the sample of eligible uninsured 19 to 34 year olds, on which most findings in this Data Note are based, is plus or minus 6 percentage points. Numbers of respondents and margin of sampling error for other age groups are show in the table below. To access a more detailed methodology, please see the online report.

Kaiser Family Foundation analysis of CMS data, downloaded from: https://data.cms.gov/dataset/The-Number-of-Estimated-Eligible-Uninsured-People-/pc88-ec56. For the purposes of this Data Note, the ‘eligible uninsured’ are California residents ages 19-64 who have been uninsured for at least two months, and would be eligible for participation in the ACA coverage expansion based on their self-reported status as a citizen, permanent resident, or lawfully present immigrant.

Because eligibility for two of the law’s main components – the Medi-Cal expansion and the tax credits to help purchase insurance on the new exchanges – is based on an individual’s family income relative to the federal poverty level (FPL), in some cases we report survey results among the eligible uninsured by FPL categories. Those with incomes 138% FPL or less (roughly $32,000 a year for a family of 4) will be eligible for Medi-Cal coverage, while those with incomes greater than 138% and up to 400% FPL (roughly $32,000-$94,000 for a family of 4), will be eligible for subsidies to purchase insurance through Covered California, the state’s new marketplace. Those with incomes above 400% FPL will be allowed to buy insurance through Covered California, but will not be eligible for subsidy assistance. For convenience, we will sometimes refer to the group with incomes 138% FPL or less as the “Medi-Cal target group”, and those greater than 138% and up to 400% FPL as the “exchange subsidy target group”.